GENERAL Why is MVP Health Care (MVP) implementing an MSK Program focused on hip, knee, shoulder and spine surgeries?

Magellan Healthcare 1 Musculoskeletal Care Management (MSK) Program Hip, Knee, Shoulder & Spine Surgeries Frequently Asked Questions (FAQ s) For MVP Health Care Ordering Physicians Question GENERAL Why is MVP Health Care (MVP) implementing an MSK Program focused on hip, knee, shoulder and spine surgeries? Answer The Musculoskeletal Care Management program is designed to improve quality and manage the utilization of non-emergent* surgeries, occurring in outpatient and inpatient settings. Musculoskeletal surgeries are a leading cost of health care spending trends Variations in patient care exist across all areas of surgery (care prior to surgery, type of surgery, surgical techniques and tools, and post-op care) Diagnostic imaging advancements have increased diagnoses and surgical intervention aligning with these diagnoses rather than patient symptoms Medical device companies marketing directly to consumers Surgeries are occurring too soon leading to the need for additional or revision surgeries The following procedures require prior authorization*** through Magellan Healthcare: Outpatient Interventional Spine Pain Management Services*: Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis) Sacroiliac Joint Injections 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. 1 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

Outpatient and Inpatient Hip Surgery Services: ** Revision/Conversion Hip Arthroplasty Total Hip Arthroplasty/Resurfacing Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincher & labral repair) Hip Surgery Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy) Outpatient and Inpatient Knee Surgery Services: ** Revision Knee Arthroplasty Total Knee Arthroplasty (TKA) Partial-Unicompartmental Knee Arthroplasty (UKA) Knee Manipulation under Anesthesia (MUA) Knee Ligament Reconstruction/Repair Knee Meniscectomy/Meniscal Repair/Meniscal Transplant Knee Surgery Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration) Outpatient and Inpatient Shoulder Surgery Services: ** Revision Shoulder Arthroplasty Total/Reverse Arthroplasty or Resurfacing Partial Shoulder Arthroplasty/Hemiarthroplasty Shoulder Rotator Cuff Repair Shoulder Labral Repair Shoulder Surgery Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy) Outpatient and Inpatient Spine Surgery Services: Lumbar Microdiscectomy Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy) 2 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

Lumbar Spine Fusion (Arthrodesis) With or Without Decompression Single & Multiple Levels Cervical Anterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression (without fusion) Cervical Artificial Disc Replacement Cervical Anterior Decompression (without fusion) *A separate prior authorization number is required for each procedure ordered. **Surgeon must request surgery authorization for each joint, even if bilateral joint surgery is to be performed on the same date. ***Magellan Healthcare does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed. Why did MVP select Magellan Healthcare to manage its MSK program for hip, knee, shoulder and spine surgeries? Which MVP members will be covered under this relationship and what networks will be used? IMPLEMENTATION What is the implementation date for this MSK program for hip, knee, shoulder and spine surgeries? PRIOR AUTHORIZATION When is prior authorization required? Magellan Healthcare was selected to partner with us because of its clinically driven program designed to effectively manage quality and patient safety, while ensuring appropriate utilization of resources for MVP membership. Magellan Healthcare will manage non-emergent outpatient and inpatient hip, knee, shoulder and spine surgeries for MVP s fullyinsured membership effective March 1, 2018 through MVP s contractual relationships. Implementation will be March 1, 2018. Prior authorization is required through Magellan Healthcare for inpatient and outpatient non-emergent hip, knee, shoulder and spine surgeries listed. 3 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

The ordering physician must obtain prior authorization with Magellan Healthcare prior to performing surgery/procedure. Facility admissions do not require a separate prior authorization. However, the facility should ensure that a Magellan Healthcare prior authorization has been obtained prior to scheduling the surgery/procedure. Is a prior authorization required for patients who already have a musculoskeletal surgery scheduled? Who can order a musculoskeletal surgery? Are pain management procedures included in this program? Who will be reviewing the surgery requests and medical information provided? Does the Magellan Healthcare s prior authorization process change the requirements for facility-related prior authorization? How does the ordering physician obtain a prior Yes. Any non-emergent hip, knee, shoulder and spine surgery performed on or after March 1, 2018 requires a prior authorization through Magellan Healthcare. Musculoskeletal surgeries requiring medical necessity review are expected to be ordered by one of the following specialties: Orthopedic Surgeons Neurosurgeons Yes. All non-emergent outpatient Interventional Pain Management (IPM). Procedures are required to have a prior authorization through Magellan Healthcare. Please refer to IPM Frequently Asked Questions. As a part of the Magellan Healthcare clinical review process, actively practicing, orthopedic surgeon specialists (hip, knee and shoulder) or neurosurgeons (spine) will conduct the medical necessity reviews and determinations of musculoskeletal surgery cases. No. Magellan Healthcare s medical necessity review and determination is for the authorization of the surgeon s professional services and type of surgery being performed. Magellan Healthcare will provide MVP with the surgery type requested and authorization determination. The ordering physician must obtain prior authorization with Magellan Healthcare prior to performing surgery/procedure. Facility admissions do not require a separate prior authorization. However, the facility should ensure that a Magellan Healthcare prior authorization has been obtained prior to scheduling the surgery/procedure. Ordering Physicians will be able to request prior authorization via the Magellan Healthcare website or by calling the Magellan Healthcare toll-free number at 1-866-249-1578. 4 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

authorization from Magellan Healthcare? What information will Magellan Healthcare require in order to receive prior authorization? To expedite the process, please have the following information ready before logging on to the web site or calling the Magellan Healthcare Call Center at 1-866-249-1578 for prior authorization of nonemergent inpatient and outpatient hip, knee, shoulder and spine surgeries: (*denotes required information) Name and office phone number of ordering physician* Member name and ID number* Requested surgery type* Name of facility where the surgery will be performed* Anticipated date of surgery* Details justifying the surgical procedure*: o Clinical Diagnosis* o Date of onset of back pain or symptoms /Length of time patient has had episode of pain* o Physician exam findings (including findings applicable to the requested services) o Diagnostic imaging results o Non-operative treatment modalities completed, date, duration of pain relief, and results (e.g., physical therapy, epidural injections, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication) Please be prepared to provide the following information, if requested: Clinical notes outlining type and onset of symptoms Length of time with pain/symptoms Non-operative care modalities to treat pain and amount of pain relief Physical exam findings Diagnostic Imaging results Specialist reports/evaluation Does the ordering physician need a separate request for all spine procedures being performed during the same surgery on the same date of service? No. Magellan Healthcare will provide a list of surgery categories to choose from and the MVP surgeon must select the most complex and invasive surgery being performed as the primary surgery. Example: Lumbar Fusion If the MVP surgeon is planning a single level Lumbar Spine Fusion with decompression, the surgeon will select the single 5 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

level fusion procedure. The surgeon does not need to request a separate authorization for the decompression procedure being performed as part of the Lumbar Fusion Surgery. This is included in the Lumbar Fusion request. Example: Laminectomy If the MVP surgeon is planning a Laminectomy with a Microdiscectomy, the surgeon will select the Lumbar decompression procedure. The surgeon does not need to request a separate authorization for the Microdiscectomy procedure. If the MVP surgeon is only performing a Microdiscectomy (CPT 63030 or 63035), the surgeon should select the Microdiscectomy only procedure. Will the ordering physician need to enter each CPT procedure code being performed for a hip, knee, shoulder or spine surgery? Are instrumentation (medical device), bone grafts, and bone marrow aspiration included as part of the lumbar or cervical fusion authorizations? What kind of response time can ordering physician expect for prior authorization? No. Magellan Healthcare will provide a list of surgery categories to choose from and the ordering physician must select the primary surgery (most invasive) being performed. There will be a summary of which CPT codes fall under each procedure category. Yes. The instrumentation (medical device), bone grafts, and bone marrow aspiration procedures commonly performed in conjunction with musculoskeletal surgeries are included in the authorization; however, the amount of instrumentation must align with the procedure authorized. Having the following information available prior to calling Magellan Healthcare at 1-866-249-1578 or online through www.radmd.com will create the most efficient turnaround time of a medically necessity decision. Clinical Diagnosis Date of onset of back pain or symptoms /Length of time patient has had episode of pain Physician exam findings (including findings applicable to the requested services) Pain/Patient Symptoms Diagnostic imaging results 6 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

What will the Magellan Healthcare authorization number look like? If requesting authorization through RadMD and the request pends, what happens next? Can RadMD be used to request retrospective or expedited authorization request? How long is the prior authorization number valid? Is prior authorization necessary for lumbar, cervical, hip, knee or shoulder surgery if MVP Health Care is NOT the member s primary insurance? If an ordering physician obtains a prior authorization number does that guarantee payment? Non-operative treatment modalities completed, date, duration of pain relief, and results (e.g., physical therapy, epidural injections, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication) Generally, within 2 business days after receipt of request with full clinical documentation, a determination will be made. In certain cases, the review process can take longer if additional clinical information is required to make a determination. The Magellan Healthcare authorization number will consist of 8 or 9 alpha-numeric characters. In some cases, the ordering surgeon may instead receive a Magellan Healthcare tracking number (not the same as an authorization number) if the surgeon s authorization request is not approved at the time of initial contact. Ordering physicians will be able to use either number to track the status of their request online or through an Interactive Voice Response (IVR) telephone system. You will receive a tracking number and Magellan Healthcare will contact you to complete the process. No, those requests will need to be called into Magellan Healthcare s Call Center for processing at 1-866-249-1578. The authorization number is valid for 90 days from the date of service/date of request. Yes. An authorization number is not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits. Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. 7 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

Magellan Healthcare s medical necessity review and determination is for the authorization of the surgeon s professional services and type of surgery being performed. The ordering physician must obtain prior authorization with Magellan Healthcare prior to performing the surgery/procedure. Facility admissions do not require a separate prior authorization. However, the facility should ensure that a Magellan Healthcare prior authorization has been obtained prior to scheduling the surgery/procedure. Does Magellan Healthcare allow retroauthorizations? It is important that key physicians and office staff be educated on the prior authorization requirements. Claims for hip, knee, shoulder or spine surgeries, as outlined above that have not been properly authorized will not be reimbursed. What happens if I have a service scheduled for March 1, 2018? Can an ordering physician verify an authorization number online? Will the Magellan Healthcare authorization number be displayed on the MVP s web site? What if I disagree with Magellan Healthcare s determination? Physicians performing hip, knee, shoulder or spine surgeries should not schedule or perform these surgeries without prior authorization. An authorization can be obtained for all non-emergent hip, knee, shoulder, lumbar and cervical spine surgeries, occurring in outpatient and inpatient settings, for dates of service March 1, 2018 and beyond, beginning February 19, 2018. Magellan Healthcare and MVP Health Care will be working with the provider community on an ongoing basis to continue to educate providers that authorizations are required. Yes. Ordering physicians can check the status of member authorization quickly and easily by going to the Web site at www.radmd.com. No. SCHEDULING PROCEDURES In the event of a prior authorization or claims payment denial, providers may appeal the decision through MVP. Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification. 8 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

Do ordering physicians have to obtain an authorization before they call to schedule an appointment? Magellan Healthcare asks where the surgery is being performed and the anticipated date of service. Ordering physicians should obtain prior authorization before scheduling the patient for the surgery. WHICH MEDICAL SURGEONS ARE AFFECTED? Which physicians are impacted by the MSK Program? Neurosurgeons and Orthopedic Surgeons are the key physicians impacted by this program. All procedures performed in any setting are included in this program: Hospital (Inpatient & Outpatient Settings) Ambulatory Surgical Centers CLAIMS RELATED Where do rendering providers/surgeons send their claims for outpatient, nonemergent MSK services? How can claims status be checked? Who should a surgeon contact if they want to appeal a prior authorization or claims payment denial? MISCELLANEOUS How is medical necessity defined? MVP rendering providers/surgeons should continue to send claims directly to MVP. Rendering providers/surgeons are encouraged to use EDI claims submission. Rendering providers/surgeons should check claims status via the MVP s website or by calling our Provider Services Department at 1-866-249-1578. Rendering providers/physicians/surgeons are asked to please follow the appeal instructions given on their non-authorization letter or Explanation of Benefits (EOB) notification. Magellan Healthcare defines medical necessity as services that: Meets generally accepted standards of medical practice; be appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient evidence and professionally recognized standards; Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome; Be appropriate to the intensity of service and level of setting; Provide unique, essential, and appropriate information when used for diagnostic purposes; 9 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries

Be the lowest cost alternative that effectively addresses and treats the medical problem; and rendered for the treatment or diagnosis of an injury or illness; and Not furnished primarily for the convenience of the member, the attending physician, or other surgeon. How will referring/ordering surgeons know who Magellan Healthcare is? Will ordering physician trainings be offered closer to the March 1, 2018 implementation date? Where can an ordering physician find Magellan Healthcare s Guidelines for Clinical Use of MSK Procedures? What will the Member ID card look like? Will the ID card have both Magellan Healthcare and MVP information on it? Or will there be two cards? MVP will send notification letters and educational materials to plan surgeons. MVP and Magellan Healthcare will also conduct educational webinars prior to the implementation date for ordering physicians/surgeons. Magellan Healthcare will conduct provider training sessions prior to the implementation date. Magellan Healthcare s Clinical Guidelines can be found on the Web site at www.radmd.com. They are presented in a PDF file format that can easily be printed for future reference. Magellan Healthcare s clinical guidelines have been developed from practice experiences, literature reviews, specialty criteria sets and empirical data. The MVP Member ID card will not change and will not contain any Magellan Healthcare identifying information on it. CONTACT INFORMATION Who can a surgeon Ordering Physicians can contact Charmaine S. Everett, Sr. Provider contact at Magellan Relations Manager, at 1-800-450-7281 ext. 32615 or Healthcare for more cseverett@magellanhealth.com. information? 10 MVP Health Care FAQ MSK Hip, Knee, Shoulder and Spine Surgeries